Why does da Vinci 5 change things so much?

Da Vinci 5 - by Intuitive

I'm not sure if everyone is fully up to speed on why Intuitives da Vinci 5 changes the game in surgical robotics. And beyond that, why it changes the game in laparoscopy... and dare I say Surgery.

Let me give you my thoughts on why this is such a game changer.

But isn't it just an Xi with an insufflator?

Outwardly the bedside unit in many respects looks very much like an Xi. It has the same joint configuration, same reach, same X-boom. Same instrument interface and same footprint.

And that my friends was a very very purposeful move by Intuitive.

They know that the bedside robot in that shape and size can do every single procedure they want it to do. From thoracic, to prostates to hernias to colorectal surgery.

It does everything that millions of data points across millions of cases from the Xi prove it can do. So why ruin a great formula?

Nah. You missed the bait n switch.

DV5 vs Xi by Intuitive

If all that data and safety data, and proecdure data is valid for the Xi size n shape - then that all grandfathers onto the DV5 if you keep it the same size n shape. You just need a small delta study to show that "It's the same as the Xi." - that is what they did.

That was critical for the FDA clearance they received. And is one of maybe the biggest and most important determinants of their continued leadership in the next 5 years.

Every other new robot on the market in the USA will have to start from zero. No data - no history. So they will do multiple IDEs and be able to get one procedure after another with IDE plus IDE etc etc. It will take years to even get to procedure parity.

It's hard for me to describe how devastating that can be for a company. No matter who you are as a company - because it means you do not have a commercially viable offering verses DV5 until you get to a certain critical mass of procedures. Gone are the days when a hospital buys a robot for just one small group of users in one specialty. Robots need to be busy all day every day to make economic sense.

If your robot can only do say... Urology, and only prostate. It's no more than a curiosity of publications for a large University - but it's not a work horse for 99% of hospitals.

Why would you buy a system that can only do one procedure when you can buy a DV5 that can do every single thing the Xi can do. (And it feels the same as an Xi.)

Oh that's right... because it drives just like an Xi - you just need a small training on the buttons - so if you have a fleet of Xis - well it just pops right in - so it is easy to add it to an existing fleet. Or easy to do an upgrade.

For everyone else it is off for 2 or 3 days training. And that becomes a barrier. A big barrier.

Intutive may not look to be "out there in innovation" with a radical deisgn change. And that was bloody smart. It means it feels "familiar" and that counts a lot for the US market where hospitals are really "adding" systems - not just being first time robotics users.

(oh and if you are a first time robotic user - you'll have force feedback to help you get up the learning curve and a raft of proctors that are required to train you.)

So that "It looks like an Xi and feels like an Xi" is actually genius... and here's why...

DV5 is not an Xi

To get clearance it is "just like an Xi" - but for the user experience, and what is under the hood is a brilliant new experience.

If you are part of a management team in a competitor - sniggering at the "white Xi" then, sorry to say, you are in the wrong industry. You understand very little about what they have just brought to the table.

I've spoken with users that have been on the DV5, and already done cases: and the feedback has been glowing:

"It's faster!"

"It's more precise."

"It feels smoother and more responsive."

"It feels really next generation."

"The image on the new screen is way better."

"It is so comfortable to sit at the new console."

"It's familiar but better."

"It is way easier to set up and get going."

this is because under the skin of the bedside unit - it is all change. Modernised and improved - and "tuned" based upon millions of cases. Modern components and engineering bring a new level of feeling to the system.

The console is also way more modern - and adjustable - and a much better experience. The new haptics have way better back drive and feeling - it feels faster - more responsive - more "tuned."

And from the console you can do so much more without needing to waste time asking staff to do things - it just helps the procedure start faster - flow better - and end faster.

This is not an Xi. And keep in mind a lot of the under the hood features are still turned off - or not delivered yet. I mean why give all the candy at once?

Use the Force Luke

Many people are thinking force feedback is a gimmick that you don't need. Well - guess again. Even in preliminary data the 43% less force applied could be meaningful clinically.

But it's not that - again feedback from some big time Xi users has been super positive on the Force Feedback...

Intuitive DV5 force feedback

"I never thought I would say this - but when it's on - it's amazing."

"Once you try it, it is hard to go back. it's nice."

"This will really help new robot users through the learning curve."

Not only is it nice - it's now the premium bar for all others to chase. And that will be five years to a decade away for the others to nail force feedback. So DV5 retains the premium slot yet again - the innovation slot - the feature slot.

Every other robot will feel like a "dumb" - slow - feelingless robot.

It is also a critical way for Intuitive to segment their instrument offering. And now they have a range of segments with force feedback instruments sitting atop the pile and basic 20 plus lives simple instruments at the bottom. it allows them to retain higher pricing per case on critical procedures. But they can use the Xi instruments for many cases (leveraging all the cost economics) which is an amazing operational coup.

It all feels similar (but it's not) - Instruments and scopes all get sterilised in a similar way to the Xi - no new training - no new baskets or washing machines - so it allows the seamless integration of the DV5 in to a fleet of Xis. It just fits without too much fuss.

If you want to add in say a HUGO - you have a total restart on everything. Nothing is the same. Training - data - set up - storage - sterilising instruments - draping... everything is a new learning curve.

Why (as an established Xi hospital) would you put yourself through that pain? Especially if it only does urology.

Let's talk image chain and spare image system on the da Vinci 5

Now I'm going to get into some of the juice on imaging. Imaging chains have the business end (the scope) and then the camera (the chips) and then the imaging box and light box - then the processing - then the display.

The only change (robot side) of the imaging chain so far is that the final part of the chain - the screens in the console (and extra tower screen) - have been upgraded. Screen technology over the last ten years has lept forwards. Higher resolution - better colour rendition - better clarity - better black points and higher brightness. the DV5 console has upgraded to 4K screens ready - with brighter, better displays.

So even if you take the old camera - and pump that image to this display - it already feels way better. Even though the camera and the NIR (near infra red) is the same. Nothing has changed from the Xi - but what they eyes see in the DV5 console is way way better.

And in. the middle of that chain is the "image processing unit" which undoubtably after a decade has had some serious upgrades - ready for a next gen camera.

So what candy is coming? Well if your processing units are upgraded - and your screen is upgraded - then the minute you upgrade the camera and scope (all part of the same for Intuitive with chip on stick) - and make a few changes to the algorithms and camera chips for NIR (ICG) - you can very quickly get DV5 to a next generation imaging.

With "simple" changes from a user perspective - that DV5 goes from HD 3D black and white ICG - to 4K 3D full colour ICG with just the change of a camera and turning on new software in ther .uprated processor.

Why is this so important? Because the market is going this way, and because that is what many surgeons in manual laparoscopy (the hold outs) will demand before they switch to the robot. It is an upgrade that ticks so many boxes. 4K, white-light ICG, higher resolution and image quality.

The second part of the image chain I want to talk about is image overlay. All that compute power is ready to project cool and useful stuff onto the display of the user - and that is where the magic will happen. Anatomical structure and surgical tool analysis - tissue boundaries - 3D dynamic MRI image reconstruction - assistive help "do this step next" "Your dissection is not wide enough" - and you will be able to beam proctors straight into the heads up display for telestration etc. This is going to help users in a way that seemed science fiction five years ago.

I'm assuming much of that "help" is turned off for two reasons - one regulatory - and two why give all the candy to the kids all at once.

When this all gets turned on - this is a potentially massive game changer for case speed - safety - and clinical outcomes.

People talk about "democratising surgery" - these assistive features are that reality - and i suspect they are already under the hood of the DV5 today.

Steve - you keep going on about that second imaging system - why?

Sorry - for this I need to start to discuss why one of the biggest changes is the addtion of this new tower and some of its features. But let me start with "they plonked a handheld camera on top of the tower" why?

Intuitive da Vinci 5 tower

Often for the Xi to get a case going you need to put "optical" guided ports (trocars) into the adbomen. And the robot 3D scope system is not ideal for that. It's big - it's bulky. So historically they would wheel in say.. a Stryker secondary lap tower so they could use the hand help laparoscope to do first entry. Then often (if they didn't want to move the insufflator) they would keep the tower there - next to the Xi tower to run the case.

So basically you end up with 4 footprints in the operating room - bedside unit - console - Xi tower - accesory lap tower.

And remember, if it's being used with the robot, that lap tower is now blocked for the robotic case... not that efficient. So you need another tower next door to let the general surgeon do their lap cases at the same time. It's effectively a poor use of the tower.

So the new DV5 tower delivers a double whammy. First it has a handheld "access" camera so you no longer need to wheel in a Stryker tower for that. And well.. if you're doing that then add an insufflator so you don't need a second tower at all.

That delivers a lot of advantages - but one of the big ones is a sudden 25% reduction in footprint occupancy of the OR as you no longer need that second tower in the room. That is one of the major barriers to ASCs and OPDs which have limited space and OR floor. Less equipment is better.

Now what it also does is start to change the game. The insufflator negates the need for an insufflator accessory - and now that insufflator starts to talk to all the other components - and can be controlled by the surgeon from the console. And it is no ordinary insufflator.

It is high flow - low pressure - constant pressure and volume.

It is also smoke clearing.

This is right in the realm of Conmed and Airseal - which has been a long term partner of Intuitive - and well for DV5 cases you no longer need an Airseal. That market has just been yanked from under Conmed.

Also, that connected and smart insufflator will give a way way better experience for the user. Clear vision (smoke extraction starts the second you create smoke with the energy unit.)

And no more collapsed abdomens when meshes are introduced.

And low pressure laparoscopy which is shown to be better for patients.

And it is throwing off vital data that adds even more info to the data ecosystem.

It is a game changer - and now makes DV5 independent of any other manufacturer's towers - and they scoop up those consumables (the tubing sets etc). Nice little revenue stream.

Hand held camera with ICG

Oh sorry I forgot to finish up on the second camera and imaging system. And I left out something important. You would never ever need to use ICG for entry for ports. So why the hell did they add all that expense and make that camera an NIR system.... hmmmm I wonder.

"Steve - they could bring in a second angle of the camera when they need to a second angle and ICG."

Yep they could. But not that often. Instead - you could technically do a full lap case with that hand held camera on that tower. Technically you could use the insufflator for a hand help lap case. Technically you could use their energy unit for a hand help lap case.

And technically if that tower is in the OR when there's a non robotic case going on between robotic cases - say like in an ASC - (just saying) - then technically you don't need another Stryker tower being wheeled in and out.

Oh and technically you could scoop up all that case data and video into the My Intuitive app via the Hub.

And technically you could now do comparative analytics with lap and robotic.

And tecghnically you start to understand the full case load of a user... not just robotic...

And technically you now have an "all day system."

Why jump out of the ecosystem when you don't need to?

Oh and just for good measure - 3D image inputs - video outputs - analysis - control of OR functions - telestration for lap and robotic - integrated energy and insufflation that can all be controlled from the console - the tower - or the bedside unit. And it all talks to the EMR.

Erm why would anyone ever invest in a smart OR ever again? Stryker? Storz? wanna explain? The DV5 tower and the way it works more or less just made every OR you put it into a smart OR. I think it is potentially a big hit to all the companies that make integrated smart ORs.

It is especially impactful in ASCs where it hard to ever justify a smart OR - so this now changes the game and makes a DV5 very attractive - not just as a robot.

It also totally upends the economics around the robot - as you are no longer just buying the robot - you buy a whole tower that could be used for lap (120K saving) and no need for a smart OR (massive saving). The economic attractiveness of a DV5 just went through the roof.

So I'm not saying that Intuitive is going after towers and OR companies and insufflation companies -- per se. But Each DV5 places has a disruptive effect on the OR architecture and towers and smart ORs, they all become collateral damage.

The DV5 tower has moved the robot from a robot to an integral part of any minimally invasive OR. That is one of the biggest changes we will see in the next 5 years.

Global impact

The ability for an upgrade from Xi to DV5 in the biggest and most important market (US) has a global rippling effect. Every Xi that is out there today in the USA has already been paid for by Intuitive to build it and install it. It has already been getting revenues against that cost. When that Xi comes back into Intutive - it gets refurbished and is ready to deploy to markets with demand. Europe, Asia and latin America are ripe for robotics. And it's heating up with competition. Intuitive can now simply redeploy those Xi systems at favorable rates - leases - pay per click - service models. They now have the ability to remove that one barrier - upfront capital in many of their next growth markets. Amd deploy a cost effective - preowned system.

That will not only help them to gain rapid growth of their installed base - but will increase consumables demand globally. And at the same time deliver a killer blow to any company that planned to "sell" capital. It will hammer every P&L sheet of every competing company as everyone is forced to a PPC model or service model. None of them will be able to get that install windfall that they had all hoped for. that change in income means sales revenues are deffered. And that hits the early years P&L.

And for Intuitive it has a mass of already - once loved Xis to power that hammer blow -- Genius.

Then guess what - in five years DV5 gets regulatory cleared in those markets and there is another upgrade cycle into that established Xi customer base... rinse and repeat.

Xi assets may see 3 owners in their lifetime - creating 3 reveune streams - and all at one cost of goods. It will allow secondary and tertiary markets to be competitive for Intuitive for a decade to come. And remove any "niche" a competitor thought they would gain advantage in.

So what?

If you just read all that and are still asking "so what?" then I'm not sure you get what this means. So let me spell it out as a summary.

Intuitive have made a leap ahead - but in a clever way by retaining much of the Xi architecture to get broad clearances - that jumps them years ahead of competiton.

DV5 is a total "under the skin" upgrade - which even hard core Xi users are saying "is very different" - but it remains familiar - so no need to re-train. Boom. Instamt upgrade.

The tower is a genius move to get an instant 25% footprint reduction and now make it more appealing to smaller spaces - eg ASCs.

The smart tower basically makes smart ORs redundant - kills other low pressure high flow insufflators - reduces the need for hospitals to buy more stand alone towers - and scoops up all that lovely data.

Under the hood - the DV5 is ready for upgrade after upgrade - in vision - software - assitive features. They just need turning on one after another to keep DV5 feature set competitive for a decade.

Force feedback has ensured that the DV5 is the premium system - yet again moving the goal posts in technology - user experience and tender specifications. It allows them tiered instrument pricing to keep procedure values up where they want. Yet be competitive where they need to be competitive.

It uses Xi instrumentation - so they get mass leverage off their installed base - immediate acces to the only stapler and avanced energy on a robot. DV5 doesn't start from scratch - it starts from a trusted base - and that is hard for anyone to compete with.

It has raised the bar in robotics - and it has shifted the game in laparoscopy - as well as opening up new users to come across - new procedures that will now make workflow sense - new sites of care where the overall economics and size will now make sense (you can't just look at the price of the robot any more with DV5.) You have to consider it in the whole OR cost structure.

I think it impacts surgery as a whole, as I beleive that it will bring many surgeons and their procedures across the line to robotics. They will not only bring their laparosdcopic procedures - but even many open proceures will come across and become MAS Robotic.

In short - it just changed the game.

These are just opinions of the author based on public facts and marjet feedback. It is intended to only be for educational purposes.